New York State Department of Health
WATER SYSTEM OPERATION REPORT
Bureau of Water Supply Protection
Microbiological Sample Results
Public Water System Name
Reporting Month/Year
Date Report Submitted
__ __/ 2 0 __ __
MM Y Y Y Y
__ __/__ __/ 2 0 __ __
MM DD Y Y Y Y
County
Town, Village or City
Source Water Type (s)
Surface
Ground
GWUDI
Purchase with subsequent chlorination
Purchase w/out subsequent chlorination
Public Water System ID
NY ___ ___ ___ ___ ___ ___ ___
DATE
Source(s)
in use
Treated water
volume
(1,000 gallons/day)
Gaseous
Chlorine
Cylinder
used per
weight
day
(lbs.)
(lbs.)
Chlorination
Liquid
Hypochlorite
added to crock
(gallons or quarts)
Other Treatments / Readings
Free chlorine
residual at
entry point
(mg/l)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
TOTAL
AVG.
Chlorine Mix Ratio = __________________________ quarts/gallons of ________________________ % chlorine added to _____________________gallons of water in crock.
Reported by:____________________________________
Title: ____________________________ NYSDOH Operator Certification Number: _______________________
Signature: _____________________________________________________
DOH-360 (02/05) Page 1 of 2
Date: ___________________________ Operator Grade Level: ________________________
Microbiological Samples and Free Chlorine Residual
Sample
Location
Date
of
Sample
Sample
Type
1.Routine
2. Repeat
Total
Coliform
Positive
E.coli
Positive
Free
Chlorine
Residual
(mg/l)
Population Served:__________________________
Number of microbiological monitoring samples required:_______
Number of microbiological monitoring samples taken: _________
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
□ No□
Did an M&R violation occur? Yes
If “Yes,” check reason (s) below:
___Actual number of samples is fewer than required
___Did not collect/analyze repeat sample
___Did not collect/analyze for E. coli for positive total coliform
from routine / repeat sample
□ □
Did an MCL violation occur? Yes
No
If “Yes,” check reason(s) below (see also Part 5, Table 6 for
Additional information).
___For systems collecting less than 40 samples per month: two or
more of the samples (routine and/or repeat) are positive for
total coliform (= total coliform MCL violation).
___For systems collecting 40 or more samples per month: more
than 5% of the samples (routine and/or repeat) are positive for
total coliform (= total coliform MCL violation).
___The original sample was E.coli positive and at least 1 repeat
sample was positive for total coliform (= E.coli MCL
violation).
Reminder: System must collect a minimum of five (5) routine
microbiological monitoring samples during the month following a
repeat sample collection.
As required by 5-1.72, “Operation of a Public Water System,” a
copy of this form shall be sent to your local health department by
the 10th calendar day of the next reporting period.
Sample Collector(s): ________________________________________________________________________________________________________________________
Name of NYSDOH Certified Laboratory: _______________________________________________________________________________________________________
Did any MCL violation occur? If so, please describe: _____________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
Did an emergency or low pressure problem occur? Did source water bypass an existing treatment process in the system? If so, please explain: ______________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
Comments:________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________
DOH-360 (02/05) Page 2 of 2